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complications

Complications

Complications were defined as any deviation from the normal postoperative course occurring within 30 days of surgery 1).

To score the severity of a clinical complication, several scales have been proposed and applied in neurosurgery.

Kosic reported that between 46% and 65% of complications in hospitals occur during surgery, resulting in significant loss of revenue 2). According to scientists at the World Health Organization 3), globally, inpatient surgical complications account for 25% of medical errors annually. In the United States, annual costs due to medical errors account for $17 billion USD, with preventable surgical errors costing healthcare organizations nearly $1.5 billion USD annually 4).

Classification

Preoperative identification of neurosurgery patients with a high risk of in-hospital complications

Advanced age (≥ 60-65 years), elevated C reactive protein level (> 3 mg/L), and high Helsinki ASA score (Class 4) were associated with in-hospital systemic and infectious complications, and a combination of these could identify one-fourth of the patients with postoperative complications. Moreover, this combination of preoperative assessment parameters was significantly associated with increased resource use.

In a first prospective and unselected cohort study of outcome after elective craniotomy, simple preoperative assessments identified patients with a high risk of in-hospital systemic or infectious complications as well as extended resource use. Presented risk assessment methods may be widely applicable, also in low-volume centers, as they are based on composite predictors and outcome events 5).

Example listing of patients used in the monthly staff discussion of complications in Zurich

(November 2015).

Age

Subtotal

Intervention

Number of surgeries on this patient

Surgery due to complications

Length of stay in hospital after surgery

New neurological deficit

First time epileptic seizure

Recurrent bleeding

Death within 30 days after surgery

Other complication

Urinary tract infection

Number of complications noted at discharge

Place of residence after discharge

Surgeon of first intervention

Skull treatment

External ventricular drain

Case series

2016

In 2013, Sarnthein et al., have installed a patient registry focused on cranial neurosurgery. Surgeries are characterized by indication, treatment, location and other specific neurosurgical parameters. Preoperative state and postoperative outcome are recorded prospectively using neurological and sociological scales. Complications are graded by their severity in a therapy-oriented complication score system (Clavien Dindo Grading system, CDG). Results are presented at the monthly clinical staff meeting.

Data acquisition compatible with the clinic workflow permitted to include all eligible patients into the registry. Until December 2015, they have registered 2880 patients that were treated in 3959 surgeries and 8528 consultations. Since the registry is fully operational (August 2014), they have registered 325 complications on 1341 patient discharge forms (24%). In 64% of these complications, no or only pharmacological treatment was required. At discharge, there was a clear correlation of the severity of the complication and the Karnofsky Performance Status (KPS, ρ = -0.3, slope -6 KPS percentage points per increment of CDG) and the length of stay (ρ = 0.4, slope 1.5 days per increment of CDG).

While the therapy-oriented complication scores correlate reasonably well with outcome and length of stay, they do not account for new deficits that cannot be treated. Outcome grading and complication severity grading thus serve a complimentary purpose. Overall, the registry serves to streamline and to complete information flow in the clinic, to identify complication rates and trends early for the internal quality monitoring and communication with patients. Conversely, the registry influences clinical practice in that it demands rigorous documentation and standard operating procedures 6).

2015

The aim of this article is to investigate the frequency of neurosurgical complications according to Landriel-Ibañez Classification and their impact on patients' health status.

Patients undergoing neurosurgical procedures were enrolled in an observational longitudinal study at Neurological Institute Carlo Besta from January 2012 to September 2013. We evaluated patients' health status before surgery, at discharge, and follow-up with the Karnofsky Performance Status Scale (KPS), whereas the Landriel-Ibañez Classification was used to record complications. Descriptive statistics were performed to illustrate the distribution of sociodemographic and clinical data. We used nonparametric tests to compare KPS scores of patients with different grades of complication and to evaluate the differences between preoperative KPS scores, KPS scores at discharge and follow-up. The effect sizes were also calculated.

They enrolled 1008 patients. They registered 228 complications (139 grade 1 complications, 63 grade 2 complications, 20 grade 3 complications, and 6 grade 4 complications). All patients with a complication showed KPS scores at discharge that were lower than preoperative scores and KPS scores at follow-up greater than scores at discharge. After patients with grade 4 complications, who had the worst outcomes, those with grade 3 complications were the most compromised after surgery whereas patients with grade 2 complications seemed to have a better health status than patients with grade 1 complication.

The study highlights the impact of neurosurgical complications on patients' life and contributes to the debate on how define and classify adverse events because a classification only based on treatment seems to be not adequate 7).

2011

Each grade was classified as surgical complications or medical complication. An observational test of this system was conducted between January 2008 and December 2009 in a cohort of 1190 patients at the Hospital Italiano de Buenos Aires.

Of 167 complications, 129 (10.84%) were classified as surgical, and 38 (3.19%) were classified as medical complications. Grade I (mild) complications accounted for 31.73%, grade II (moderate) complications accounted for 25.74%, and grade III (severe) complications accounted for 34.13%. The overall mortality rate was 1.17%; 0.84% of deaths were directly related to surgical procedures.

Landriel Ibañez et al., present a simple, practical, and easy to reproduce way to report negative outcomes based on the therapy administered to treat a complication. The main advantages of this classification are the ability to compare surgical results among different centers and times, the ability to compare medical and surgical complications, and the ability to perform future meta-analyses 8).

Articles

Postoperative neurosurgery complication in 2017: A new window to take into account surgical ischaemic events 9).

1)
Landriel Ibañez FA, Hem S, Ajler P, Vecchi E, Ciraolo C, Baccanelli M, Tramontano R, Knezevich F, Carrizo A. A new classification of complications in neurosurgery. World Neurosurg. 2011 May-Jun;75(5-6):709-15; discussion 604-11. doi: 10.1016/j.wneu.2010.11.010. PubMed PMID: 21704941.
2)
Kosic K 2015 Raise patient care and lower hospital costs by reducing surgical errors Available from https://adora-med.com/blog/raise-patient-care-and-lower-hospital-costs-byreducing-surgical-errors/[Accessed May 2018]
3)
Semel ME, Resch S, Haynes AB et al 2009 Adopting a surgical safety checklist could save money and improve the quality of care in US hospitals Available from: https://www. healthaffairs.org/doi/abs/10.1377/hlthaff.2009.0709 [Accessed May 2018]
4)
Agency for Healthcare Research and Quality 2008 New AHRQ study finds surgical errors cost nearly $1.5 billion annually Available from https://archive.ahrq.gov/news/newsroom/ press-releases/2008/surgerr.html [Accessed May 2018]
5)
Reponen E, Korja M, Niemi T, Silvasti-Lundell M, Hernesniemi J, Tuominen H. Preoperative identification of neurosurgery patients with a high risk of in-hospital complications: a prospective cohort of 418 consecutive elective craniotomy patients. J Neurosurg. 2015 Sep;123(3):594-604. doi: 10.3171/2014.11.JNS141970. Epub 2015 May 1. PubMed PMID: 25932609.
6)
Sarnthein J, Stieglitz L, Clavien PA, Regli L. A Patient Registry to Improve Patient Safety: Recording General Neurosurgery Complications. PLoS One. 2016 Sep 26;11(9):e0163154. doi: 10.1371/journal.pone.0163154. eCollection 2016. PubMed PMID: 27669157.
7)
Schiavolin S, Broggi M, Acerbi F, Brock S, Schiariti M, Cusin A, Visintini S, Leonardi M, Ferroli P. The Impact of Neurosurgical Complications on Patients' Health Status: A Comparison Between Different Grades of Complications. World Neurosurg. 2015 Jul;84(1):36-40. doi: 10.1016/j.wneu.2015.02.008. Epub 2015 Feb 18. PubMed PMID: 25701767.
8)
Landriel Ibañez FA, Hem S, Ajler P, Vecchi E, Ciraolo C, Baccanelli M, Tramontano R, Knezevich F, Carrizo A. A new classification of complications in neurosurgery. World Neurosurg. 2011 May-Jun;75(5-6):709-15; discussion 604-11. doi: 10.1016/j.wneu.2010.11.010. PubMed PMID: 21704941.
9)
Bombled C, André A, Jacquens A, Clarençon F, Degos V. Postoperative neurosurgery complication in 2017: A new window to take into account surgical ischaemic events. Anaesth Crit Care Pain Med. 2017 Aug;36(4):203-204. doi: 10.1016/j.accpm.2017.07.001. PubMed PMID: 28780988.
complications.txt · Last modified: 2018/07/25 09:12 by administrador